Authors: Robin Cook
Jack closed his eyes and tried to think of how two people from central supply could possibly have come down with two different fatal infectious diseases. As far as he was concerned, it could not be a coincidence. He was convinced their illnesses had to be work-related. The question was how?
In his mind’s eye, Jack revisited central supply. He could picture the shelving and the aisles, even the outfits the employees wore. But nothing came to mind as a way for the employees to come in contact with contagious bacteria. Central supply had nothing to do with the disposal of hospital waste or even soiled linen, and as the supervisor had mentioned, workers there had little or no contact with patients.
Jack read the rest of Janice’s investigative report. As she’d done with the cases since Nodelman, she included information about pets, travel, and visitors. For Maria Lopez, none of the three seemed a factor.
Jack opened the second folder. The patient’s name was Joy Hester. In this case Jack felt there was little mystery. She’d been an OB-GYN nurse and had had significant exposure to Susanne Hard just prior to and after the onset of Susanne’s symptoms. The only thing that bothered Jack was recalling that he’d read that person-to-person transmission of tularemia rarely occurred.
The third case was Donald Lagenthorpe, a thirty-eight-year-old petroleum engineer who’d been admitted to the hospital the previous morning. He’d come in through the ER with a refractory bout of asthma. He’d been treated with IV steroids and bronchodilators as well as humidified air and bed rest. According to Janice’s notes, he’d shown steady improvement and had even been campaigning to be released, when he’d had the sudden onset of a severe frontal headache.
The headache had started in the late afternoon and was followed by shaking chills and fever. There was also an increase in cough and exacerbation of his asthmatic symptoms despite the continued treatment. At that point he was diagnosed to have pneumonia, which was confirmed by X ray. Curiously enough, however, a gram stain of his sputum was negative for bacteria.
Myalgia also had become prominent. Sudden abdominal pain and deep tenderness had suggested a possible appendicitis. At seven-thirty in the evening Lagenthorpe had undergone an appendectomy, but the appendix proved to be normal. After the surgery his situation became progressively grave with apparent multisystem failure. His blood pressure dropped and became unresponsive to treatment. Urine output became negligible.
Reading on in Janice’s report, Jack learned that the patient had visited isolated oil rigs in Texas the previous week and had literally been tramping around in desert conditions. Jack also learned that Mr. Lagenthorpe’s girlfriend had recently obtained a pet Burmese cat. But he’d not been exposed to any visitors from exotic places.
“Wow! You’re here early!” Laurie Montgomery exclaimed.
Jack was shocked out of his concentration in time to see Laurie sweep into the ID room and drape her coat over the desk she used for her early-morning duties. It was the last day of her current rotation as supervisor in charge of determining which of the previous night’s cases should be autopsied and who would do them. It was a thankless task that none of the board-certified doctors enjoyed.
“I’ve got some bad news for you,” Jack said.
Laurie paused on her way into communications; a shadow passed over her usually bright, honey-complected face.
Jack laughed. “Hey, relax,” he said. “It’s not that bad. It’s just that you owe me a quarter.”
“Are you serious?” she asked. “The Hard case was tularemia?”
“The lab reported a positive fluorescein antibody last night,” Jack said.
“I think it’s a firm diagnosis.”
“It’s a good thing I didn’t bet any more than a quarter,” Laurie said. “You are amassing some impressive statistics in the infectious arena. What’s your secret?”
“Beginner’s luck,” Jack said. “By the way, I have three of last night’s cases here. They’re all infectious and all from the General. I’d like to do at least two of them.”
“I can’t think of any reason why not,” Laurie said. “But let me run over to communications and get the rest.”
The moment Laurie left, Vinnie made his appearance. His face was a pasty color and his heavily lidded eyes were red. From Jack’s perspective he appeared as if he belonged in one of the coolers downstairs. “You look like death warmed over,” Jack said.
“Hangover,” Vinnie remarked. “I went to a buddy’s bachelor party. We all got whacked.”
Vinnie tossed his newspaper on a desk and went over to the cupboard where the coffee was stored.
“In case you haven’t noticed,” Jack said, “the coffee is already made.”
Vinnie had to stare at the coffee machine with its full pot for several beats until his tired mind comprehended that his current efforts were superfluous.
“How about starting on this instead?” Jack said. He pushed the Maria Lopez folder over to Vinnie. “Might as well get set up. Remember, the early bird...”
“Hold the clichés,” Vinnie said. He took the folder and let it fall open in his hands. “Frankly, I’m not in the mood for any of your sappy sayings. What bugs me is that you can’t come in here when everybody else does.”
“Laurie’s here,” Jack reminded him.
“Yeah, but this is her week for scheduling. You don’t have any excuse.”
He briefly read portions of the folder. “Wonderful! Another infectious case! My favorite! I should have stayed in bed.”
“I’ll be down in a few minutes,” Jack said.
Vinnie irritably snapped up his newspaper and headed downstairs.
Laurie reappeared with an armful of folders and dumped them on her desk. “My, my, but we do have a lot of work to do today,” she said.
“I’ve already sent Vinnie down to get prepared for one of these infectious cases,” Jack said. “I hope I’m not overstepping my authority. I know you haven’t looked at them yet, but all of them are suspected plague but tested negative. At a minimum I think we have to make a diagnosis.”
“No question,” Laurie said. “But I should still go downstairs and do my external. Come on, I’ll do it right away, and you can get started.” She grabbed the master list of all the previous night’s deaths.
“What’s the story on this first case you want to do?” Laurie asked as they walked.
Jack gave her a quick synopsis of what he knew about Maria Lopez.
He emphasized the coincidence of her being employed in central supply at the General. He reminded her that the plague victim from the day before had also worked in that department. They boarded the elevator.
“That’s kinda strange, isn’t it?” Laurie asked.
“It is to me,” Jack agreed.
“Do you think it’s significant?” Laurie asked. The elevator bumped to a stop, and they got off.
“My intuition tells me it is,” Jack said. “That’s why I’m eager to do the post. For the life of me, I can’t figure out what the association could be.”
As they passed the mortuary office Laurie beckoned to Sal. He caught up to them, and she handed him her master list. “Let’s see the Lopez body first,” she said.
Sal took the list, referred to his own, then stopped at compartment 67, opened the door, and slid out the tray. Maria Lopez, like her late co-worker, Katherine Mueller, was an over-weight female. Her hair was stringy and dyed a peculiar reddish orange. Several IVs were still in place. One was taped to the right side of her neck, the other to her left arm.
“A fairly young woman,” Laurie commented.
Jack nodded. “She was only forty-two.”
Laurie held Maria Lopez’s full-body X ray up to the ceiling light. Its only abnormality was patchy infiltration in her lungs. “Go to it,” Laurie said.
Jack turned on his heels and headed toward the room where his moon suit ventilator was charging.
“Of the other two cases you had upstairs, which one would you want to do if you only do one?” Laurie called after him.
“Lagenthorpe,” Jack said.
Laurie gave him a thumbs-up.
Despite his hangover, Vinnie had been his usual efficient self in setting up the autopsy on Maria Lopez. By the time Jack read over the material in Maria’s folder for the second time and had climbed into his moon suit, all was ready.
With no distractions from anyone in the pit besides himself and Vinnie, Jack was able to concentrate. He spent an inordinate amount of time on the external exam. He was determined to find an insect bite if there had been one. He was not successful. As with Mueller, there were a few questionable blemishes, which he photographed, but none he felt were bites.
Jack’s concentration was inadvertently aided by Vinnie’s hangover. Preferring to nurse his headache, Vinnie remained silent, sparing Jack his usual quips and running commentary on sports trivia. Jack reveled in the thought-provoking silence.
Jack handled the internal exam the same way he’d handled those of the previous infectious cases. He was extraordinarily careful to avoid unnecessary movement of the organs to keep bacterial aerosolization to a minimum.
As the autopsy progressed, Jack’s overall impression was that Lopez’s case mirrored that of Susanne Hard, not Katherine Mueller. Hence, his preliminary diagnosis remained tularemia, not plague. This only highlighted his confusion of how two women from central supply had managed to catch these illnesses while other, more exposed hospital workers had avoided them.
When he finished with the internal exam and had taken the samples he wanted, he put aside a special sample of lung to take up to Agnes Finn. Once he had similar samples from Joy Hester and Donald Lagenthorpe, he planned to have them all sent immediately to the reference lab to be tested for tularemia. By the time Jack and Vinnie had commenced stitching up Maria Lopez, they began to hear voices in the washroom and out in the hall.
“Here come the normal, civilized people,” Vinnie commented.
Jack didn’t respond. Presently the door to the washroom opened. Two figures entered in their moon suits and ambled over to Jack’s table. It was Laurie and Chet.
“Are you guys finished already?” Chet said.
“It’s not my doing,” Vinnie said. “The mad biker has to start before the sun is up.”
“What do you think?” Laurie asked. “Plague or tularemia?”
“My guess is tularemia,” Jack said.
“That will be four cases if these other two are tularemia as well,” Laurie said.
“I know,” Jack said. “It’s weird. Person-to-person spread is supposed to be rare. It doesn’t make a lot of sense, but that seems par for the course with these recent cases.”
“How is tularemia spread?” Chet asked. “I’ve never seen a case.”
“It’s spread by ticks or direct contact with an infected animal, like a rabbit, Jack said.
“I’ve got you scheduled for Lagenthorpe next,” Laurie told Jack. “I’m going to do Hester myself.”
“I’m happy to do Hester as well,” Jack said.
“No need,” Laurie said. “There aren’t that many autopsies today. A lot of last night’s deaths didn’t need to be posted. I can’t let you have all the fun.”
Bodies began arriving. They were being pushed into the autopsy room by other mortuary techs and lifted onto their designated tables. Laurie and Chet moved off to do their own cases. Jack and Vinnie returned to their suturing. When they were finished, Jack helped Vinnie move the body onto a gurney. Then Jack asked how quickly Vinnie could have Lagenthorpe ready to go.
“What a slave driver,” Vinnie complained. “Aren’t we going to have coffee like everybody else?”
“I’d rather get it over with,” Jack said. “Then you can have coffee for the rest of the day.”
“Bull,” Vinnie said. “I’ll be reassigned back in here helping someone else.”
Still complaining, Vinnie pushed Maria Lopez out of the autopsy room. Jack wandered over to Laurie’s table. Laurie was engrossed in the external exam but straightened up when she caught sight of Jack.
“This poor woman was thirty-six,” Laurie said wistfully. “What a waste.”
“What have you found? Any insect bites or cat scratches?”
“Nothing except a shaving nick on her lower leg,” Laurie said. “But it’s not inflamed, so I’m convinced it’s accidental. There is something interesting. She has definite eye infections.”
Laurie carefully lifted the woman’s eyelids. Both eyes were deeply inflamed, although the corneas were clear.
“I can also feel enlarged preauricular lymph nodes,” Laurie said. She pointed to visible lumps in front of the patient’s ears.
“Interesting,” Jack commented. “That’s consistent with tularemia, but I didn’t see it on the other cases. Give a yell if you come across anything else unusual.”
Jack stepped over to Chet’s table. He was happily engrossed in a multiple gunshot wound case. At the moment he was busy photographing the entrance and exit wounds. When he saw Jack he handed the camera to Sal, who was helping him, and pulled Jack aside.
“How was your time last night?” Chet asked.
“This is hardly the best time to discuss it,” Jack said. Conversation in the moon suits was difficult at best.
“Oh, come on ,” Chet said. “After the China Club we went back to her pad on East Sixty-sixth. I had a blast with Colleen.”
“I’m happy for you,” Jack said.
“What did you guys end up doing?” Chet asked.
“You wouldn’t believe me if I told you,” Jack said.
“Try me,” Chet challenged. He leaned closer to Jack.
“We went over to her office, and then we came over here to ours,” Jack said.
“You’re right,” Chet said. “I don’t believe you.”
“The truth is often difficult to accept,” Jack said.
Jack used Vinnie’s arrival with Lagenthorpe’s corpse as an excuse to return to his table. Jack pitched in to help set up the case because it was preferable to further grilling by Chet. Besides, it made it possible to start the case that much sooner.